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Nursing has never had so much information at its fingertips - gigabytes of data accessible in nanoseconds. Yet, our effectiveness and successes continue to be measured in breaths, heartbeats per minute, and quality of life. The truth is that we cannot save lives or keep sick patients functioning or even maintain healthy people with just a click on the keyboard - despite the amount of data we access with a single keystroke. Our best shot at success lies in our commitment to advanced education, the ability to assimilate new information, and to integrate this knowledge into the development of new patient care delivery models.
Is nursing becoming more specialized? A resounding "Yes," says Phyllis Shanley Hansell, RN, EdD, FAAN, professor and dean of Seton Hall University, College of Nursing, in South Orange, N.J., and there is consensus among many of her nurse educator, practitioner, and credentialing colleagues. Many experts support the premise that a trend in nursing specialization is, in fact, in progress. This trend is consistent with RNs who are seeking higher education, advanced degrees, and credentialing. "There is definitely a movement into nursing specialization," says Hansell. Some nursing specialties, Hansell explains, have evolved in the acute care clinical setting, such as ostomy care or the specialized care of patients who require specific procedures or surgeries. "However," Hansell says, "specialization, for example, of the clinical nurse specialist, nurse practitioner, certified nurse midwife, or nurse anesthetist, carry academic credentials awarded at the university level."
Historically, says Mary O' Neil Mundinger, RN, DrPH, dean and centennial professor in Health Policy, Columbia University School of Nursing, Manhattan, "The trend toward specialization actually began in the '70s and '80s with the primary care movement and nurse practitioner movements." Those original movements focused mostly on primary care. "Now we're seeing many more specializations focused on patients who are inhospital. So, specialization in nursing is going to continue to increase because the needs of patients are going to increase, wherever patients are treated, because their needs are going to require it."
Another nod for nursing specialization comes in the form of a recent study by the American Association of Critical-Care Nurses and the AACN Certification Corporation, which verifies that clinical competency through nursing specialty certification is increasingly recognized, valued, and supported by nurses themselves, their employers, and the public. Additional data from the same white paper, Safeguarding the Patient and the Profession: The Value of Critical Care Nurse Certification, shows that specialty certification is associated with increased job satisfaction, fewer medical errors, and higher retention levels of nurses.1
It pays to certify
The complex needs of today's patients require the type of care that is equally as complex. In order to provide patients with the best care possible, nurses must know more about a broad spectrum of patient care needs that include areas such as case management, holistic practices, pain management, etc., and they need to know now. Certification and certificate programs offer another route to advanced nursing education, typically requiring fewer credits than most traditional post-graduate degrees. Nursing has more than 60 specialty nursing organizations, and there are almost as many certifications as there are nursing specialties. Although the AACN and the American Board of Nursing Specialties (ABNS) offer national certifications in varied specialties, some specialty organizations, like the Association of Nurses in AIDS Care, for example, offer their own certifications as well.
Certificate programs are offered by a number of schools of nursing, in may different specialties. These programs usually consist of five or six courses (18 or more credits) and can take up to one year to complete. In addition to its master's and doctorate programs, Seton Hall offers certificates in case management/health administration, childbirth education, and school nursing, and post-master's certificates for RNs who wish to become
nurse practitioners.
The numbers tell the story
The notion that nurses are becoming more specialized is also evidenced by the rise in numbers of certifications in areas of nursing specialty and enrollment in postgraduate degree programs such as master's, advanced practice, and doctorate of nursing programs. Even the programs themselves are becoming more specialized. Columbia's master's program has a number of "subspecialties," including alcohol and substance abuse, clinical genetics, emergency preparedness response, and HIV/AIDS. Similarly, Rutgers is in the process of developing a post-master's certificate program in clinical trials [http://nursing.rutgers.edu/
academic-programs/postmasters.asp]. But the proof is in the pudding of current statistics compiled by the Health Resources and Services Administration (HRSA).2
The big picture of nursing, according to the latest statistics by the HRSA, show the total number of licensed RNs living and working in the U.S. as of March 2004 has increased from 2,696,540 in 2000, to 2,909,467 in 2004. According to the same survey, RNs are aiming toward higher levels of education. Nurses are increasingly prepared with baccalaureate, master's, or doctorate degrees.2 In fact, the highest increase from 2000 to 2004 was in RNs receiving their master's or doctorate degrees - 37% - an increase of 101,978 RNs compared to a decrease of 91,495 RNs whose highest degree earned was a diploma.2
There were 40,461 more RNs prepared to practice in at least one advanced practice role in 2004 than in 2000 (244,461 versus 196,000 RNs). The largest group among advanced practice nurses was nurse practitioners, followed by clinical nurse specialists. These two groups together, including those with dual or multiple training as a nurse practitioner, clinical nurse specialist, nurse midwife, and/or nurse anesthetist, comprised 82.8% (199,000 nurses) of all advanced practice nurses.2 A separate assessment, a survey prepared by the American Academy of Nurse Practitioners (AANP), points out that there were 106,000 NPs practicing in 2003-2004 in 12 areas of NP specialty.3
Med-surg units obsolete?
Felissa R. Lashley, RN, PhD, ACRN, FAAN, FACMG, dean and professor, Rutgers, The State University of N.J., College of Nursing, Newark, is confident that med-surg units will continue to be prominent in the patient care setting, and other experts share her point of view. "I don't think med-surg units are going to be a thing of the past," says Mundinger. "I think they're going to be more specialized. Nurses now are certainly caring for more intensive patients. We will see smaller units, but they'll be more specialized - not the large wards with mixed medical patients."
"There is a huge nursing work force. What's needed are generalists as well as nurses with specialties. However, increasingly, the hospitalized patient requires more than RN generalist care," Mundinger continues. "Hospitals today, in many ways, look like ICUs did years ago. With that kind of complexity, intensity, and acuity, generalist skills alone are no longer adequate to provide the kind of care today's hospitalized patients require."
"We will still need generalists," agrees Hansell, "but the care of the 'typical' med-surg patient has become very complex. In the past, a patient may have been hospitalized with gallbladder disease. Now that admitted patient may have diabetes, a history of hypertension, heart disease, may be a cancer survivor, and have a host of emotional needs, too."
Patients are increasingly challenged by pharmacologic interventions, drug interactions, and health care illiteracy. "And, with the technological overlay, it further complicates care," Hansell says. "It's a good part of the reason why we need nurses with baccalaureate and advanced degrees."
As demographics and societal shifts stretch the demands on the health care delivery system, estimated through 2020, gerontology, chronic disease management, women's health, psychiatric and advanced practice credentials will be required.
Nurses must also consider socioeconomic factors that complicate the delivery of comprehensive patient care, including the rising incidence of single-parent families, blended families, and individuals living alone.
Nursing to a higher degree
New developments are on the table and on their way through the pipeline. Years in the making, the members of the American Association of Colleges of Nursing (AACN) endorsed the Position Statement on the Practice Doctorate in Nursing by the Task Force on the Practice Doctorate. AACN member institutions voted to change the current level of preparation necessary for advanced nursing practice from the master's degree to the doctorate level by 2015.4
According to the AACN, "The AACN Board of Directors has formed a Task Force on the Roadmap to the [doctor of nursing practice] to study the full array of implications and issues resulting from this new direction in nursing education. The task force is charged with examining DNP program development, master's-to-doctoral transition programs, regulations and licensure, reimbursement for advanced practice nurses (APN), and other issues. AACN will continue to work with an array of stakeholders, including APN groups, the higher education community, and health care providers, to determine the best ways to implement the DNP."2
"The knowledge and skill that advanced practice nurses need grow exponentially each year," says Lashley, proponent of advanced degrees in nursing practice and the new doctorate. "The doctor of nursing practice degree recognizes this need and allows for a professional doctorate that is clinically based."
There are currently seven doctor of nursing practice degree programs accepting students nationwide, including programs at Case Western Reserve University, Columbia University, Rush University, Tri-College University, the University of Kentucky, the University of South Carolina, and the University of Tennessee Health Science Center. The University of Colorado Health Sciences Center is also in the process of transforming its Doctor of Nursing degree (ND) into a Doctor of Nursing Practice program. More than 40 additional programs are now under development, including programs at Oakland University, Oregon Health & Science University, the University of Illinois at Chicago, the University of Iowa, the University of Pittsburgh, and the University of South Florida.4,5
New developments, new concerns
This new trend raises a host of questions concerning continuity of patient care, patient care coordination, and assurance of optimal patient care outcomes. How will patients and their families fare in this new climate of advancing knowledge, technology, and advanced nursing expertise? "The purpose of specialization is to provide the patient with the highest level of expert care available," says Hansell. "Nursing is responsive to the trends in health care by addressing the complexities of these issues. I think we're going to be out there in the front lines making a difference for the patients and their families." But, only time will tell how successful nursing specialization will ultimately be. We'll have to wait and see - one nanosecond at a time.
Agnes H. Geoghegan, RN, BS, is a freelance writer for Nursing Spectrum. To comment on this article, e-mail jspillane@nursingspectrum.com.
Editor's Note: References available upon request and in the online version of this article.
For more information -
· American Association of Colleges of Nursing Program Lits. Available at: http://www.aacn.nche.edu/
DNP/DNPProgramList.htm.
· Columbia University's Doctor of Nursing Practice Degree. Available at: http://cpmcnet.columbia.edu/
dept/nursing/programs/drnp_approved.html..